In Mary LaClair v. Suburban Hospital, Inc., Mary T. LaClair, individually and as the personal representative of the estate of her husband, Cameron J. LaClair, Jr. (“Mr. LaClair”), appealed the Maryland district court’s order finding that Suburban Hospital, Inc. (“Suburban”), and Physical Therapy and Sports Medicine (“PTSM”), were joint tortfeasors with respect to injuries her husband sustained while he was a patient at Suburban. Applying several provisions of the Restatement (Second) of Torts, each of which was grounded in the idea that an intervening act is not a superseding cause if it was foreseeable at the time of the primary negligence, the United States Court of Appeals for the Fourth Circuit determined that the harm and injuries sustained by Mr. LaClair at Suburban were foreseeable consequences of the alleged negligence of PTSM. Thus, Senior District Judge Peter J. Messitte held that Suburban’s actions were not a superseding cause of Mr. LaClair’s injuries, and Suburban and PTSM were joint tortfeasors in accordance with the district court’s ruling.

On November 1, 2007, Mr. LaClair, a “vibrant former CIA officer” in his mid-80s, sustained an injury while receiving physical therapy at the PTSM facility. He was attempting to secure himself in a piece of exercise equipment and fell onto the floor, while his physical therapist had stepped away. He was taken by ambulance to Suburban, where he was diagnosed with a cervical fracture and dislocation. On November 3, 2007, Alexandros Powers, M.D., a neurosurgeon at Suburban, performed surgery on Mr. LaClair. The surgery entailed Dr. Powers inserting screws and rods to secure Mr. LaClair’s spine. According to Dr. Powers, the surgery “was successful and proceeded without complication, and Mr. LaClair’s prognosis at that time included a complete and total recovery free from future cervical spine surgery.” Dr. Powers also stated that, as of the morning of November 6, 2007, Mr. LaClair had “recovered and was to be discharged [from Suburban] to a rehabilitation facility” the next day, and “there was no plan or expectation for subsequent cervical spine surgeries due to the success of the November 3 surgery.”

Later on November 6, Mr. LaClair needed assistance using the bathroom, and two (2) patient care technicians responded. Mr. LaClair used the bathroom, and the patient care technicians attempted to reposition him in his hospital bed. According to Mrs. LaClair, her husband’s “head was violently pushed against the side rail of the bed and he cried out in pain,” because one (1) of the patient care technicians was “very rough.” Dr. Powers examined Mr. LaClair and found a fracture of the C7 endplate, dislocation at C6/C7, dislodging of the screws placed in previous surgery, and several other post-surgical disruptions. Dr. Powers determined that Mr. LaClair could no longer be discharged on November 7 as previously scheduled, but instead needed to undergo an additional surgery on November 8. Mr. LaClair underwent a third surgery on February 6, 2008, at Georgetown University Hospital. He spent nearly five (5) months hospitalized, underwent plaster casting of his cervical spine, developed bedsores, and ultimately required a feeding tube.

The LaClairs filed two (2) separate lawsuits: first, against PTSM for injuries stemming from the November 1 incident (filed March 19, 2009) (the “PTSM lawsuit”), and second, against Suburban for “separate and distinct” injuries stemming from the November 6 incident. The PTSM lawsuit alleged that PTSM was responsible for not only the injuries and damages incurred from the November 1 incident at PTSM’s facility, but also the injuries and damages incurred from the November 6 incident at Suburban. During discovery, however, Dr. Powers testified that the injuries stemming from the November 1 incident were “separate, distinct, and divisible” from those sustained by the November 6 incident. Subsequently, the LaClairs settled with PTSM for $1 million on March 5, 2010. The Settlement Agreement specifically recognized that the LaClairs would be pursuing separate claims against Suburban, in connection with the November 6 incident alone.

The Suburban lawsuit, filed about six (6) weeks after the PTSM settlement, alleged that Mr. LaClair suffered injuries from the November 6 incident that were separate and distinct from those of the November 1 incident. This litigation settled on May 31, 2011. Pursuant to the Settlement Agreement between the LaClairs and Suburban, however, the parties agreed to submit to the district court the question of whether PTSM and Suburban were joint tortfeasors in connection with the November 6 incident, or whether those injuries were separate and distinct such that Suburban alone would be liable. Additionally, pursuant to the Settlement Agreement, Suburban agreed to make an initial $650,000 payment to the LaClairs and further agreed to make an additional payment of $600,000 in the event that the court found PTSM and Suburban were not joint tortfeasors as to the November 6 incident.

The district court held a motions hearing on January 20, 2012. Finding that these injuries were reasonably foreseeable, the district court decided that Suburban was indeed a joint tortfeasor with PTSM such that Mrs. LaClair could not recover additional damages. Mrs. LaClair appealed to the Fourth Circuit. On appeal, the Fourth Circuit began its analysis by stating that PTSM would not be jointly liable for the November 6 incident “if it appear[ed] highly extraordinary and unforeseeable that the plaintiffs’ injuries [on November 6] occurred as a result of [PTSM’s] alleged tortious conduct.” Pittway Corp. v. Collins, 973 A.2d 771, 788 (Md. 2009). Accordingly, PTSM would avoid liability for the November 6 incident “only if the intervening negligent act,” i.e., Suburban’s conduct, “[wa]s considered a superseding cause of the harm to” Mr. LaClair. See Morgan v. Cohen, 523 A.2d 1003, 1004‒05 (Md. 1987).

Relying on Pittway and Section 442 of the Restatement (Second) of Torts, the court first noted that it would be hard-pressed to find a case regarding subsequent negligent medical care in which there was not a “separate and distinct” injury after the injury caused by the initial actor’s negligence. Second, the appellate court agreed with the district court that Suburban’s actions were not “so extraordinary as to bring about a conclusion of separate intervening cause.” The court clarified that foreseeability, as an element of proximate cause, permits a retrospective consideration of the total facts of the occurrence. The court determined that PTSM might have had no reason to expect that Mr. LaClair would be injured by being repositioned in his hospital bed, but the proper way to view the situation was after-the-fact, “knowing that such a force has intervened.” Finally, the appellate court inquired into whether Suburban’s actions were “a normal consequence of a situation created by the actor’s negligent conduct,” and whether the manner in which the intervening act was done was “extraordinarily negligent.” RESTATEMENT (SECOND) TORTS §§ 443, 447(c) (1965). Even if the patient care technicians were “very rough,” the court opined this alone would not rise to the level of “extraordinarily negligent” conduct. Therefore, the appellate court did not find that the negligence of the patient care technicians, either in manner or consequence, was abnormal or extraordinary.

In conclusion, the court stated that any doubt that the Restatement Section 442 factors weighed in favor of Suburban would be resolved by an analysis of Section 447: PTSM should have realized that an elderly man injured by a fall from its own exercise equipment would have to go to the hospital, would receive medical care, and may possibly experience negligent medical care there. Mr. LaClair’s ultimate injuries and the manner in which they occurred were not extraordinary, nor were these unfortunate consequences unforeseeable. For these reasons, the Fourth Circuit affirmed the judgment of the district court.